Used for medical claim reporting in all healthcare settings, ICD-10-CM is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, abnormal findings, signs and symptoms, injuries, external causes of injuries and diseases, and social circumstances.
What is ICD-10. The ICD tenth revision (ICD-10) is a code system that contains codes for diseases, signs and symptoms, abnormal findings, circumstances and external causes of diseases or injury. The need for ICD-10. Created in 1992, ICD-10 code system is the successor of the previous version (ICD-9) and addresses several concerns.
The coding of severe sepsis requires a minimum of two codes: first a code for the underlying systemic infection, followed by a code from subcategory R65. 2, Severe sepsis. If the causal organism is not documented, assign code A41. 9, Sepsis, unspecified organism, for the infection.
ICD-10 code A41. 9 for Sepsis, unspecified organism is a medical classification as listed by WHO under the range - Certain infectious and parasitic diseases .
ICD-10 code R65. 21 for Severe sepsis with septic shock is a medical classification as listed by WHO under the range - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified .
R65. 21 Severe sepsis with septic shock - ICD-10-CM Diagnosis Codes.
Coding sepsis requires a minimum of two codes: a code for the systemic infection (e.g., 038. xx) and the code 995.91, SIRS due to infectious process without organ dysfunction. If no causal organism is documented within the medical record, query the physician or assign code 038.9, Unspecified septicemia.
When sepsis is present on admission and due to a localized infection (not a device or post procedural), the sepsis code is sequenced first followed by the code for the localized infection.
Chapter-specific guidelines state, “First code for the underlying systemic infection, followed by a code R65. 20, Severe sepsis. If the causal organism is not documented, assign code A41. 9, Sepsis, unspecified organism, for the infection.
Sepsis is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death. In other words, it's your body's overactive and toxic response to an infection. Like strokes or heart attacks, sepsis is a medical emergency that requires rapid diagnosis and treatment.
Severe sepsis with septic shock R65. 21 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM R65. 21 became effective on October 1, 2021.
Chapter-specific guidelines state, “First code for the underlying systemic infection, followed by R65. 21, septic shock. If the causal organism is not documented, assign code A41. 9, sepsis, unspecified organism, for the infection.
The code for septic shock cannot be assigned as a principal diagnosis. For septic shock, the code for the underlying infection should be sequenced first, followed by code R65. 21, Severe sepsis with septic shock or code T81.
Sepsis as Principal Diagnosis Is sepsis always sequenced as the principal diagnosis when it is present on admission? Some may say yes, because after all, that's what is stated in the official coding guidelines. However, my answer to this question is no, not always.
A41.51 Sepsis due to Escherichia coli [E. coli] N39.0. SIR S. SIRS is the body’s clinical cascading response to infection or trauma that triggers an acute inflammatory reaction and progresses to coagulation of the blood, impaired fibrinolysis, and organ failure.
Bacteremia . Bacteremia is a lab finding of infectious organisms in the blood. The patient has no clinical signs of sepsis or SIRS. Bacteremia may be transient, or may lead to sepsis. When a patient’s blood cultures are positive and not believed to be a contaminant, the patient is usually treated with antibiotics.
SIRS is manifested by two or more of the following symptoms: fever, tachycardia, tachypnea, leukocytosis, or leukopenia. Documentation issues: When SIRS is documented on the chart, determine if it’s due to an infectious or non-infectious cause. SIRS due to a localized infection can no longer be coded as sepsis in.
The discharge diagnoses were influenza with pneumonia bacterial superinfection, positive for pseudomonas, as well as acidosis, asthma exacerbation, hypoxemia, and chronic bronchitis. Sepsis and SIRS were not mentioned on the discharge summary, and are mentioned only sporadically throughout the progress notes.
For instance, if severe sepsis, pneumonia, and acute renal failure due to dehydration are documented, the code for severe sepsis may not be assigned because the acute renal failure is not stated as due to or associated with sepsis. If the documentation is unclear, query the physician.
Codes from category P36 include the organism; an additional code for the infectious organism is not assigned. If the P36 code does not describe the specific organism, an additional code for the organism can be assigned. Urosepsis. The term “urosepsis” is not coded in ICD-10-CM.
Post-procedural Sepsis and Sepsis Due to a Device, Implant, or Graft. A systemic infection can occur as a complication of a procedure or due to a device, implant, or graft. This includes systemic infections due to wound infection, infusions, transfusions, therapeutic injections, implanted devices, and transplants.
Sepsis associated with organ dysfunction distant from the site of infection.
The 2022 edition of ICD-10-CM R65.20 became effective on October 1, 2021.
Sepsis is a potentially life-threatening condition that occurs when the body’s response to an infection damages its own tissues. Without timely treatment, sepsis can progress rapidly and lead to tissue damage, organ failure, and then death. Proper coding of sepsis and SIRS requires the coder to understand the stages of sepsis and common documentation issues.
Sepsis is an extreme response to infection that develops when the chemicals the immune system releases into the bloodstream to fight infection cause widespread inflammation. This inflammation can lead to blood clots and leaky blood vessels, and without timely treatment, may result in organ dysfunction and then death. Severe cases of sepsis often result from a body-wide infection that spreads through the bloodstream, but sepsis can also be triggered by an infection in the lungs, stomach, kidneys, or bladder. Thus, it is not necessary for blood cultures to be positive to code sepsis (guideline I.C.1.d.1.a.i).
Coding tips: Only one code is needed to report sepsis without organ dysfunction. Most sepsis codes are listed in A40.- through A41.9. If a causal organism is specified, then use the code for sepsis naming the specific organism. Per AHA Coding Clinic® (Vol. 5, No. 1, p. 16), when sepsis is linked to an infection with an organism, assign the combination code for sepsis including the organism. For example, sepsis due to E. coli UTI can be coded as A41.51 and N39.0.
For instance, if sepsis, pneumonia, and acute renal failure due to dehydration are documented, the code for severe sepsis may not be assigned because the acute renal failure is not stated as due to or associated with sepsis. If the documentation is unclear, query the physician.
Severe sepsis is sepsis with acute organ dysfunction. It occurs when one or more of the body’s organs is damaged from the inflammatory response. Any organ can be affected.
Sepsis can be caused by fungi, candida, or viruses, as well. It is important to use the Alphabetic Index to select the appropriate code for the systemic infection. For example, if a patient is diagnosed with candidal sepsis due to a candida UTI, you would report B37.7 Candidal sepsis for the principal diagnosis and B37.49 Other urogenital candidiasis for the secondary diagnosis. Do not select a code from A40.- through A41.9.
SIRS is an inflammatory state affecting the whole body. It is an exaggerated defense response of the body to a noxious stressor, such as infection or trauma, that triggers an acute inflammatory reaction, which may progress and result in the formation of blood clots, impaired fibrinolysis, and organ failure.